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Smoking Withdrawal Dynamics in Unaided Quitters Journal of Abnonnal Psychology Copyright 2000 by the American Psychological Association, Inc. 2000, Vol. 109, No. 1, 74-86 0021-843X/00/$5.00 DOI: 10.1037//0021-843X.109.1.74 Smoking Withdrawal Dynamics in Unaided Quitters Thomas M. Piasecki University of Wisconsin Medical School and University of Wisconsin---Madison Raymond Niaura, William G. Shadel, Michael C. Fiore and Timothy B. Baker David Abrams, and Michael Goldstein University of Wisconsin Medical School and Brown University University of Wisconsin---Madison Considerable research shows that withdrawal severity is inconsistently related to smoking cessation outcomes. This may result from measurement problems or failure to scrutinize important dimensions of the withdrawal experience. Two recent studies demonstrated that withdrawal elevation and variations in the time course of withdrawal were related to relapse in smokers treated with the nicotine patch (T. M. Piasecki, M. C. Fiore, & T. B. Baker, 1998). This article reports a conceptual replication and extension of those findings in unaided quitters. Evidence for temporal heterogeneity was found across different types of withdrawal symptoms. Patterns or slopes of affect and urge reports over time predicted smoking status at follow-up, as did mean elevation in withdrawal symptoms. These results suggest that affect and urge withdrawal symptoms make independent contributions to relapse and that relapse is related to both symptom severity and trajectory. The study of withdrawal is at a watershed. Traditional models of because measures of withdrawal have not covaried consistently drug dependence and drug motivation have accorded withdrawal a with relapse vulnerability and other purported indices of depen- central role in motivating addictive drug use and relapse (e.g., dence. Theoreticians have offered a litany of observations that Isbell & White, 1953; Seevers, 1962; Wikler, 1973). In addition, challenge withdrawal-based accounts. These include the fact that for many years, the presence of withdrawal symptoms has consti- there is an inconsistent relation between the tendency of a drug to tuted a central criterion for the diagnosis of a drug dependence support habitual use and the severity of the drug's withdrawal disorder (American Psychiatric Association, 1994). However, re- syndrome (e.g., Jaffe, 1980). Also, drug-dependent persons fre- cent models of dependence and drug motivation have almost quently do not identify withdrawal as an instigator of relapse universally de-emphasized withdrawal as a central explanatory (Marlatt, 1985), and relapse often occurs long after the cessation of construct (cf. Heyman, 1996; Marlatt, 1985; Robinson & Berridge, drug use, when withdrawal symptoms should have abated (Bran- 1993; Vuchinich & Tucker, 1988). This has transpired largely don, Tiffany, Obremski, & Baker, 1990). Finally, the extent to which treatments suppress withdrawal does not correspond well with their ability to produce abstinence (Jorenby et al., 1995; Thomas M. Piasecki and Timothy B. Baker, Center for Tobacco Re- Transdermal Nicotine Study Group, 1991). search and Intervention, University of Wisconsin Medical School, and Various factors might account for the weak relations between Department of Psychology, University of Wisconsin--Madison; Raymond withdrawal and relapse. For instance, it may be the case that Niaura, William G. Shadel, David Abrams, and Michael Goldstein, Divi- sion of Behavioral and Preventive Medicine, The Miriam Hospital, Brown smoking withdrawal symptoms have little impact on cessation and University; Michael C. Fiore, Center for Tobacco Research and Interven- the maintenance of abstinence. Alternatively, inadequate concep- tion and Department of Medicine, University of Wisconsin Medical tualization and assessment strategies may have caused researchers School. to overlook important dimensions of the withdrawal phenomenon This research was supported in part by National Heart, Lung and Blood (Gilbert et al., 1998; Piasecki, Kenford, Smith, Fiore, & Baker, Institute Grant HL32318 and by National Institute on Drug Abuse Grant 1997). Prior to abandoning withdrawal as a vital explanatory DA07580-03. We gratefully acknowledge Claudia Morelli, Suzanne Sales, construct, it seems prudent to pursue novel approaches to the study Adrienne McParlin, Cheryl Eaton, and Alicia Fontes for their help in data collection. of withdrawal that may yield additional information about its Correspondence concerning this article should be addressed to Thomas correlates and consequences (Meehl, 1978; Patten & Martin, M. Piasecki, Center for Tobacco Research and Intervention, 7275 Medical 1996a). Indeed, investigators have begun to adopt new and inno- Sciences Center, 1300 University Avenue, Madison, Wisconsin 53706, or vative approaches to the study of withdrawal (e.g., Epping-Jordan, Raymond Niaura, The Miriam Hospital, Division of Behavioral and Watkins, Koob, & Markou, 1998; Gilbert et al., 1998; Keenan, Preventive Medicine, 164 Summit Avenue, Providence, Rhode Island Hatsukami, Pentel, Thompson, & Grillo, 1994; Shiffman et al., 02906. Electronic mail be sent to [email protected] or 1997; Swan, Ward, & Jack, 1996). Raymond Niaura @brown.edu. 74 SMOKING WITHDRAWAL 75 When a mismatch between strong theory and empirical findings nections between symptom trajectories and an array of affect and exists, measurement issues are a natural object of scrutiny (Serlin dependence indices, and we use a variety of strategies to begin & Lapsley, 1985); investigators should be reluctant to discard teasing apart the connections between postcessation smoking and venerable theories if there is a possibility that empirical discrep- withdrawal patterns. We assess the clinical relevance of atypical ancies might stem from inadequate measures. Hence, it is not withdrawal by examining the connections between categorical surprising that smoking researchers have begun to reexamine (cluster based) and continuous (simple slope) measures of with- withdrawal instruments (Patten & Martin, 1996b; Welsch et al., drawal trajectory and relapse. Central theoretical principles guid- 1999). Another tactic that can be used to reevaluate withdrawal is ing our research on withdrawal heterogeneity posit that the trajec- to start with withdrawal measures that are presumed valid and then tory of withdrawal symptoms reflects the responsivity of affective analyze them in novel ways. processing systems to pharmacologic and nonphannacologic stim- We have recently reported results from two studies examining ulation (Piasecki et al., 1997, 1998) and that affects provide a variability in the time course of withdrawal symptoms that reflect readout of motivated behavior (e.g., Baker, Morse, & Sherman, this approach to measurement evaluation (Piasecki, Fiore, & 1987; Buck, 1993). These principles give rise to the prediction that Baker, 1998). In these studies, we clustered quitters according to the affective components of the withdrawal syndrome should show the shapes of their withdrawal profiles and demonstrated that the strongest relations with relapse. atypical withdrawal, characterized by late peaks or unremitting symptoms, was quite common. Such withdrawal profiles are Method termed atypical because they diverge from the prototype generated by traditional models of withdrawal (Hughes, Higgins, & Hat- Participants and Procedure sukami, 1990). Atypical profiles were common, occurring in smokers who had lapsed and those who were abstinent and occur- Data for this report were drawn from a study of unaided quitters conducted at The Miriam Hospital in Providence, Rhode Island (Shadel et ring in smokers who received diverse interventions. Data were al., 1998). To be eligible for the study, participants had to: (a) be be- drawn from two clinical trials of the nicotine patch, and the tween 18 and 75 years of age; (b) have no decrease in the number of withdrawal scale and assessment schedules used in these trials cigarettes or nicotine content of their usual brand of cigarettes by more than conformed to common research practice. half in the previous 3 months; (c) have no use of tobacco products other Atypical profiles were not only shown to be fairly common, but than cigarettes; (d) report motivation to quit as at least 5 on a 10-point they were also related to relapse; participants with atypical profiles scale; (e) not be enrolled in any other smoking cessation program or use were more likely to relapse than were other smokers. This relation any other quitting methods (e.g., patch, gum); (f) not attempt, if female, to could involve a variety of mechanisms. For instance, smokers with become pregnant; (g) not be currently treated for ongoing psychiatric worsening symptoms might be more likely to return to smoking in disorders; and (h) not be taking medication that might interfere with order to manage their worsening symptoms. Smokers who lapse psychophysiological assessments (e.g., beta blockers). Participants visited the laboratory a total of eight times during the study. might experience an exacerbation in withdrawal due to the lapse, Three sessions occurred prior to the quit date. At the first session, partic- and this might motivate further smoking and relapse. Thus, al- ipants completed a variety of self-report measures and gave blood samples. though little is known about the mechanisms that link withdrawal At a second session, held the next day, participants underwent various profiles to relapse, there is evidence that profile shape carries experimental manipulations
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